Sherman "Red" Yoder (diabetic ulcer, LTC) 

Client history:  

- Patient is an 80-year-old male with a six-month history of Type 2 diabetes initially 

treated with oral agents and more recently started on insulin. Recently, he presented to 
his primary physician, Dr. Joshua Galloway at the Central Clinic, with an open wound on 
his right great toe. He's not entirely sure how the wound developed or how long it has 
been present. The wound was not painful and he only noticed it a few days ago as he 
was removing his socks. He called his doctor because he remembered being told to 
watch out for sores and cuts when he was diagnosed with diabetes. At the appointment, 
Dr. Galloway's office arranged home health care services for River Bend Home Health to 
make visits to Red in his home, where he lives independently. He was placed on SQ 
insulin and home health services were ordered for wound evaluation and assessment 
for home safety, blood sugar testing, insulin education, diet and any other needed 
services. 
- According to Red, when his adult son, Bren, heard about his foot wound, he insisted on 
bringing him to the emergency room for evaluation. Bren is very concerned with his 
father's health and ability to care for himself independently. Bren strongly advocated for 
an inpatient evaluation of his father's wound. The decision was made to evaluate and 
treat Red as an inpatient and he was admitted to the medical-surgical unti for IV 
antibiotics, insulin and C&S of the wound. 
- Past medical history: 
- Diabetes Type II, diagnosed 6 months ago, recently switched from oral to insulin therapy 
- Hypertension >20 years 
- BPH 
- Medications​: 
- Was previously taking Metformin 500 MG BID and was just switched to regular insulin 
per sliding scale after the development of the foot ulcer. Home health care was going to 
teach him to manage the insulin, but River Bend home health has not made a visit yet, 
so he is just initiating the SQ insulin at the time of admission. 
- spironolactone and hydrochlorothiazide (25 MG/25 MG) (Aldactazide) PO daily 
- tamsulosin (Flomax) 0.4 MG PO daily 
- Allergies: NKDA 
- Social history: 
- Sherman goes by the name "Red." He is retired. In his youth he played for the Cleveland 
Indians and was then on their coaching staff. Later, he worked for years with the 
 baseball stadium selling stadium ads and sponsorships for the Indians. He has been 
widowed for 2 years and lives alone in his own home where he has lived for >50 years. 
Red has one grown son, Bren, who lives in a suburb of Cleveland and visits his father 
regularly. Red no longer drives and since his foot ulcer, is having a hard time walking to 
and from the bus stop. He has been using taxi and ride-sharing services for 
transportation. Red shares that he very much wants to maintain his independence and 
he worries that his son is trying to "put [him] in an old folks home."   

Biochemical data, medical tests and procedures: 

- Hemoglobin A1c:10.1%H 

Anthropometric measurements: 

- Height: 72 in 
- Weight: 224 lb 
- BMI: 30.4 (obese) 

Physical exam finding (nutrition focused): 

- Eyes/ENT: No problems. 
- Cardiovascular: No problems. 
- Respiratory: No problems. 
- Gastrointestinal: No problems. Date and time of last BM: yesterday morning 
- Genitourinary: BPH. Frequent urination with difficulty initiating and maintaining stream. 
- Musculoskeletal: General weakness. 
- Skin: Ulcer on the great right toe. 
- Neurologic: Suffers from diabetic neuropathy with numbness and tingling of lower 
extremities and loss of sensation in feet. 
- ADLs: Weakness. 

Food and nutrition history: 

- No diet information was given, but it seems that the patient has uncontrolled diabetes 
so he may need diet counseling on diabetes management for consistent carbohydrates  
Comparative standards: 

- Doctor - to ensure the proper healing of the diabetic ulcer and any other diabetes 
complications that the patient may be experiencing. The doctor can also prescribe a 
new regimen if they feel as if the patients current one is not sufficient  
- Pharmacist - to give out correct doses of insulin and assist the patient when he has 
questions about his medications 
- Nurse - to monitor the patients health and wellbeing along with his blood sugar levels 
and diabetic ulcer  
- Diabetes educator - to educate the patient on how to properly manage his diabetes 
through correct usage of his insulin and diet regimen  

Total energy estimated needs: 

- Men: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5.  
- (10 x 101.8) + (6.25 x 182.88) - (5 x 80) + 5 
- 1,018 + 1,143 - 400 + 5 = 1,766 x 1.2AF = 2,119 or 2 ​ ,000 calories 

Total protein estimated needs: 

- 101.8 x 1.5 = 152.7 or 1

​ 00-150​ grams protein 
- Up the protein for a wound  

Total fluid estimated needs: 

- 1mL per kcal = ~​2L 

Nutrition Diagnosis 

(P) Problem: 

- (Predicted) Inconsistent carbohydrate intake  

(E) Etiology (r/t): 

- Related to uncontrolled diabetes  

(S) S/S (aeb): 

- As evidence by a current diabetic ulcer and a high hemoglobin A1c 

Nutrition Intervention 

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

Regular diet consisting of 2,000 calories, 100 grams protein, 2L fluids, and consistent 
carbohydrates.  

Intervention: 

- Educate the patient on the importance of proper medication usage and consistent 
carbohydrate intakes for diabetes management.  

Goal: 

- Patient will be able to demonstrate his knowledge and understanding of how to use his 
insulin and how to consume a consistent carbohydrate diet by keeping a food and 
insulin log for two weeks.  

Nutrition Monitoring and Evaluation 

Indicator: 

- Patient’s flagged labs will lower and his ulcer will show progress with healing within the 
next two weeks. 

Criteria: 

- Patient’s hemoglobin A1c will be within the normal range and his ulcer will be noticeably 
more healed than when he was admitted.  

Anna Cordova (pulmonary Embolism, Transgender)

Nutrition Assessment 

Client history: 

- Chief Complaint/Reason for Visit: shortness of breath 

- History of Present Illness: 54-year old male to female transgender patient presenting to 
the ED with a 2-day history of worsening shortness of breath. Patient recently moved 
from south Florida and reportedly did the trip “all-in-one shot”. During the drive she 
reported having some pain in her right ankle with some worsening swelling in her right 
leg. When she arrived here in Georgia she noticed that whenever she exerted herself 
she was having worsening shortness of breath. Today it was so bad that even on slight 
exertion she had to sit down and catch her breath. She reports that she did recently 
have a Depoestradiol injection as part of her hormone treatment post gender 
conversion surgery. She does have a history of COPD but denies any recent increase in 
sputum or change in sputum color/consistency. She also denies any history of coronary 
artery disease. She has had a TIA in the past. She has never had a clot before. On 
evaluation in the ED, a chest CT showed multiple bilateral clots with some straightening 
of her interventricular septum signifying right heart strain. Hemodynamically she has 
been tachycardic but her blood pressure has been stable and she has not required 
supplemental oxygen. She was given a dose of enoxaparin in the ED. 
 - Past Medical History: male to female transsexual, COPD, transient ischemicattack, 
fibromyalgia, anxiety with depression, GERD 
- Past Surgical History: transition surgery 
- Vital Signs: T 36.9 P 108 RR 19, BP 134/70 (91) Pulse Ox 93 on R 
- Allergies: cephalosporins, penicillin, aspirin  
- Family History: significant for colon cancer in her grandmother 
- Social History: 
- Occupation- desk job (recently transferred from FL to GA) 
- Support- lives alone but has a partner and several close friends living in the area 
- Tob- 1 pack per day EtOH- denies qty- n/a 
- THC- denies Coc- denies qty- n/a 
- Other- denies all recreational drug use 

Biochemical data, medical tests and procedures: 

- Labs/Imaging/Microbio (Relevant/Abnormal): 
- WBC 12.7 k/mm3 
- Hbg 12.1 gm/dL 
- Hct 37.4 % 
- Plt 222 k/mm3 
- Na 140 meq/dL 
- K 3.9 meq/dL 
- Cl 109 meq/dL 
- HCO2 24 meq/dL 
- BUN 19 mg/dL 
- Cr 1.1 mg/dL 
- Mg 2.0 mg/dL 
- Alb 4.0 gm/dL 
- Total Bili 0.25 mg/dL 
- AST 14 U/L 
- ALT 47 U/L 
- Alk Phos 57 U/L 
- Glu 173 mg/dL 
- A1c 6.5% 
- INR 1.0 (0.9-1.1) 
- D dimer (FEU) 2.52 (0-0.49) 
- Imaging​: 
- Chest CT angiogram: 
 - Impression: 1. Multiple bilateral pulmonary emboli. 2. Mild straightening of the 
intraventricular 
- septum suggesting component of right heart strain 
- CXR: 
- No acute cardiopulmonary finding  
- Meds on Admission (if hospitalized): gabapentin 300 mg TID PO, cyclobenzaprine 10mg 
PO TID, prednisone 10mg daily, trazodone 50mg PO at bedtime, Xanax 0.5mg PO twice 
daily, Depoestradiol 
- OTC/CAM: omeprazole 20mg PO daily, famotidine 20mg PO BID 
- Med Adherence? Unknown except for what patient reports 

Anthropometric measurements: 

- 102kg 
- 183cm (6’) 
- BMI: 30.6 

Physical exam finding (nutrition focused): 

- Seems to be in minor distress with no noticeable cause for the shortness of breath 

Food and nutrition history: 

- No food related history was recorded and the patient does not appear to have been 
given any nutritional counseling in the past 

Comparative standards: 

- Doctor - to make sure the patient is safe during their hospital stay and that their 
condition is not fatal  
- Cardiologist - to diagnose any heart problems that may be causing the SOB 
- Respiratory therapist - to find solutions to the SOB if necessary  
- Nurse - to monitor progress and patient’s shortness of breath  
- Pharmacist - to give correct dosages of medications prescribed by doctors  
Total energy estimated needs: 

- IBW: 5lb per inch over 5ft = 100 + 60 = 160 x .10 large frame = 16, 160 + 16 = 1
​ 76lbs 
- Women: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161 
- (10 x 102) + (6.25 x 183) - (5 x 54) - 161 
- 1,020 + 1,143.8 - 270 - 161 = 1,733 x 1.33AF = 2,304 pr 2,300 calories - 300 for weight loss 
= ​2,000 calories  

Total protein estimated needs: 

- 80 x .8 = 64 or 7
​ 0 grams protein  

Total fluid estimated needs: 

- 1mL per kcal or ​2.3L 

Nutrition Diagnosis 

(P) Problem: 

- Predicted excessive energy intake 

(E) Etiology (r/t): 

- Related to improper food choices  

(S) S/S (aeb): 

- As evidenced by obesity, elevated pertinent lab values, and clots  

Nutrition Intervention 
Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

- Regular diet consisting of 2,00 calories, 70 grams protein, 10% or less of calories from 
saturated fats, 2.3L fluid and increased fruits / vegetable intake.  

Intervention: 

- Nutrition education on heart healthy food choices including foods that thin blood (to 
help with clotting), foods that are naturally low in cholesterol or help lower body 
cholesterol, and foods low in saturated fats,  

Goal: 

- Increase healthier food choices and decrease healthy food choices in terms of saturated 
fat and cholesterol.  

Nutrition Monitoring and Evaluation 

Indicator: 

- Patient will keep a 1 week food log that shows five servings of fruits and vegetables per 
day and a saturated fat intake of 10% or less.  

Criteria: 

- Patient will have flagged labs return to normal or at least decrease within two weeks.  

 
 Somer Benedict (Eating Disorders) outpatient

Nutrition Assessment 

Client history: 

- Chief Complaint: 
- Exercise intolerance, dizziness and fatigue. 
- History of Present Illness: 
- This is a college senior who complains of dizziness and fatigue, especially during 
exercise. Symptoms began two weeks ago.  
- Patient has been noticing increased fatigue while performing daily activities and has had 
difficulty keeping to her regular routine. From the patient's initial appearance, I assumed 
this was a college athlete or marathon runner in training, but when questioned about 
her exercise routine, she replies, "I am not physically active, I only jog a little." When 
questioned further, it was learned that the patient "jogs" every morning before her 8 am 
classes for a distance of eight miles and this "jog" takes approximately one hour, which 
shows that she is not jogging, but maintaining a brisk running speed for an extended 
distance each morning. Apparently she also goes to a spinning class in the afternoon 
and does Vinyasa Yoga each evening. I calculate that she may be exercising >3 hours per 
day. She is continuing this regime, despite feeling "very run down," "tired, and even 
"dizzy" before, during and after exercising.  
- Patient denies syncope or loss of consciousness. She did have a sore throat and fever a 
few weeks ago, but says it resolved on it's own. No heart palpitations or tachycardia. No 
SOB, wheezing or cough. No c/o stomach ache, diarrhea or constipation. No arthralgias, 
but does c/o generalized weakness as described above. Denies recent weight gain or 
loss; however, our records indicate a 16# weight loss x one year. 
- Past Medical History: 
- Anorexia mixed with bulimia, with history of inpatient treatment six years ago 
- Past Surgical History: 
- None 
- Social History: 
- Patient is a college senior majoring in Political Science/International Relations. She is 
single and lives off-campus with two roommates. She does not have a job during the 
school year. She denies being an athlete or avid runner, but her history demonstrates 
otherwise. She runs 8 miles per day. She also exercises at the campus health center 
 each day by participating in spinning or aerobics classes and yoga. She denies tobacco, 
alcohol and drug use. She has a history of eating disorders, as listed in medical history.  
- Family History: 
- Has a family history of CAD and sudden death due to AMI. Father died at age 50 after MI 
while mowing the lawn. Mother is A&W. Sommer is an only child. 
- Allergies: 
- None 
- Medications: 
- Daily multivitamin for women. Patient reports use of laxative for occasional 
constipation.  
- Assessment/Plan/Discussion: 
- Female patient positive for mononucleosis. She also appears undernourished. EKG 
shows normal sinus brady. Electrolytes are normal per lab data. The dizziness and 
fatigue with exercise in this underweight but otherwise healthy female athlete, is likely 
attributed to a mono infection. EKG and electrolytes were normal today. BMI is 16.8, 
underweight. She is not menstruating and does have lanugo on face and body. She 
became visibly upset when I told her she would need to stop all exercise for the next 
two weeks due to the mono infection. I counseled her on the risks of splenomegaly, but 
she continued saying she would be "careful." I am concerned that she will continue to 
pursue aggressive exercise during this illness and did advise her that per campus policy 
I have an obligation to notify the health center of her exercise restriction. At this point 
she began to cry. Due to her history of long-standing anorexia and bulimia, I am 
concerned current exercise patterns may be a form of exercise bulimia. I am referring 
Sommer to be seen in the Valley View Therapy Center for a crisis visit at the earliest 
available appointment. She should return to this clinic in 2 weeks for follow-up related 
to her mono, or sooner with increasing sore throat, fever, fatigue or other symptoms. 
Pt would benefit from a DEXA scan.  

Biochemical data, medical tests and procedures: 

- Labs: 
- CBC:  
- Hgb 14.6 
- Hct 44% 
- RBC 5.5 
- WBC: 5,200 
- Glucose 75 
- BUN 25 
- Creat 0.8 
 - Sodium 149 
- Potassium 3.4 
- Chloride 96 
- Calcium 8.7 
- Magnesium 1.6 
- Phosphorus 3.0 
- Alk Phos 112 
- AST 30 
- ALT 21 
- Diagnostics: 
- EKG:  
- EKG shows normal sinus bradycardia, Rate 56 bpm. No abnormal qt or st segment 
changes. No t wave abnormalities.  
- Heterophile Antibody Titer (Monospot): 
- Positive 

Anthropometric measurements: 

- 107lbs 
- 67inches (5’7) 
- 16.8BMI (underweight)  

Physical exam finding (nutrition focused): 

- Examination:  
- Vital Signs: 98.4, 56, 14, 110/56. Height: 5' 7" Weight: 107 lbs (height and weight was not 
shown to patient per history of body dysmorphia) BMI 16.8 
- General: Thin and muscular female. Protruding clavicle.   
- HEENT: General inspection reveals thin and muscular face with prominent veining. Slight 
depression of temporal region. Light colored lanugo present across cheeks and lower 
jaw. Posterior oropharynx with enlarged tonsils, inflamed with erythema, clear exudate 
and cobblestoning. Gums inflamed. 
- Neck: Generalized lymph enlargement bilaterally, no thyroid enlargement. No carotid 
bruit or JVD 
- Integumentary: Light colored lanugo present throughout her face. Her color and 
temperature are normal. Reduced skin turgor. Otherwise unremarkable 
- Cardiovascular: Prominent PMI visible on visual exam. Rate bradycardic and regular. I 
hear a faint murmur in the upright position, likely a functional artifact. EKG shows 
bradycardia and sinus rhythm. 
 - Respiratory: Lungs sounds are clear with good aeration throughout. 
- Gastrointestinal: Abdomen is flat and muscular. I am unable to appreciate any 
organomegaly. Abdominal aortic pulse can clearly be seen from the abdomen. No bruit. 
Bowel sounds normoactive in all four quadrants. 
- Genitourinary: No flank pain. Genitalia not assessed. First day of LMP approx 4 1/2 
months ago. 
- Extremities: Full ROM, denies weakness at this time. Peripheral vascular exam reveals 
muscular arms and legs with very little hair or body fat. Scarring on fingers of dominant 
hand.   
- Neurological: Fully intact. 

Food and nutrition history: 

- Anorexia mixed with bulimia, with history of inpatient treatment six years ago 
- Daily multivitamin for women. Patient reports use of laxative for occasional 
constipation.  

Comparative standards: 

- Doctor - to evaluate the state of the patient’s organs and ability to function  
- Psychiatrist- to evaluate the mental state of the patient and prescribe medication if 
necessary. They will also be able to help cure the mental aspect of the patient's illness 
and will be a vital part in her recovery  
- Nurse - to monitor patient’s health and wellbeing as well as track their eating habits and 
vital signs   

Total energy estimated needs: 

- 5 x 7 = 35 +100 = 135lbs  
- AjBW = IBW + 0.4( ABW - IBW) 
- 135 - 11.2 =​ 123.8lbs  
- Women: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161. 
- (10 x 56.3) + (6.25 x 170.2) - (5 x 22) - 161 
- 563 + 1,063.8 - 110 - 161 = 1,355.8 x 1.9AF = 2,576 or ​2,500 calories  
Total protein estimated needs: 

- 56.3kg x 1g = 56 or at least​ 60 grams of protein  

Total fluid estimated needs: 

- 1mL per kcal ​= 2.5L 

Nutrition Diagnosis 

(P) Problem: 

- Inadequate oral intake 

(E) Etiology (r/t): 

- Related to increased energy expenditure  

(S) S/S (aeb): 

- As evidenced by a 2.6 decrease in BMI within the last year resulting in an underweight 
categorization  

Nutrition Intervention 

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

- Regular diet consisting of 2,000 calories, at least 60 grams of protein, 2.5L fluids, and a 
decrease in exercise.  
Intervention: 

- Provide nutrition education on the importance of fueling the body prior to and after 
exercise for optimal results. Discuss ways that the patient can consume food in less 
scary ways and plan on seeing her regularly. It is most important to build rapport with 
this client in order to see results.  

Goal: 

- Increase calorie consumption to around 2,000 calories per day and decrease exercise to 
3o minutes of light activity per day. 

Nutrition Monitoring and Evaluation 

Indicator: 

- Patient will see an increase in weight (and BMI) within the next two weeks when 
following this nutrition prescription.  

Criteria: 

- Patient will keep a 2 week food log to track all food consumed over the next two weeks 
to monitor an increase in consumption of foods, more specifically, calorie dense foods. 
She will also track activity to see a decrease in this to allow herself time to heal from her 
mono diagnosis.